7 AN ANTIBIOTIC PATHWAY FOR COMPLICATED APPENDICITIS DIRECTED BY CLINICAL RESPONSE REDUCES LENGTH OF HOSPITAL STAY
Samantha Fryer1, Mairead Stockdale1, James Bancroft1, Jennifer Orr1, Simon Kenny1, Harriet Corbett1, Nick Lansdale2
1Alder Hey Children's Hospital, Liverpool, United Kingdom. 2Royal Manchester Children's Hospital, Manchester, United Kingdom

Abstract

Aim

Despite evidence to suggest shorter durations of antibiotics are safe in complicated appendicitis in children, this practice has not been widely adopted in the UK. We aimed to determine whether a clinical pathway that tailors antibiotics to clinical condition was safe and effective.

Methods

A new post-operative pathway (NewPath) was devised that reduced mandatory intravenous antibiotics for complicated appendicitis (perforated or gangrenous) from 5 to 3 days post-operatively, provided the child was apyrexial for >12 hours and tolerating oral diet. Oral antibiotics were only given if white-blood-cell counts were raised. Data were collected prospectively (NewPath) and compared to 100 cases immediately prior to NewPath introduction. Data are presented as median [IQR]. Comparisons used the Fisher’s exact or Mann Whitney U tests as appropriate. Significance was defined as p<0.05.

Results

164 children completed the NewPath over 11 months. Age and normal appendicectomy rate were similar between groups (NewPath vs. existing care, 9y [6-12] vs.10y [7-13] and 19/164 [12%] vs.15/100 [15%]). Rates of complicated appendicitis were 88/164 [54%] vs. 42/100 [42%], p=0.08. For cases of complicated appendicitis, length of stay was shorter for the NewPath (5 [4-7] vs. 7 [6-8] days, p=0.009) and fewer required oral antibiotics on discharge (35/88 [40%] vs. 26/42 [62%], p=0.01). Readmissions within 28 days (24/88 [27%] vs. 8/42 [19%], p=0.39) and intra-abdominal collections (20/88 [23%] vs. 6/42 [14%], p=0.35) were similar between groups.

Conclusions

Post-operative appendicitis care guided by clinical progress and white-blood-cell count can reduce hospital stay and antibiotic use without increasing complications. Applied nationally, pathways such as this have the potential to save considerable health resource. High rates of intra-abdominal collections and hospital readmission highlight the challenge of complicated appendicitis in children and warrant further study.


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